Basic Information
| Provider Information | |||||||||
| NPI: | 1417907676 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JERROLD FRIEDMAN, M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1272 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080536272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567551616 | ||||||||
| FaxNumber: | 8567550098 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 E EVESHAM RD | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080439547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567511600 | ||||||||
| FaxNumber: | 8567511548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 11/05/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/19/2008 | ||||||||
| NPIReactivationDate: | 11/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | FRIEDMAN | ||||||||
| AuthorizedOfficialFirstName: | JERROLD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8567551616 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0343567000 | 01 | NJ | AMERIHEALTH HMO/PPO | OTHER | 568292 | 01 | NJ | AMERIHEALTH ADMINISTRATOR | OTHER | 2672520 | 01 | AETNA HMO | OTHER | 069469768 | 01 | NJ | TAX ID | OTHER | 5365751 | 01 | AETNA PPO | OTHER |